Medical Records Coder-Senior

UT Health San Antonio; San Antonio (TX); On-site; USD 55,000 - 75,000; Full time

Job summary

UT Health San Antonio is seeking a qualified coder to conduct inpatient and outpatient coding reviews under limited supervision, ensuring compliance with federal regulations and up-to-date coding guidelines. The role emphasizes accuracy in ICD-10 and CPT coding across medical records and documentation, with on-site responsibilities at the San Antonio location.

The ideal candidate has 5+ years of medical record abstraction and coding experience, strong communication skills, and the ability to

Qualifications

• Proficiency in ICD-10 and CPT coding.
• In-depth understanding of medical terminology, anatomy and physiology.
• Meticulous attention to detail and accuracy.
• Solid customer service acumen and interpersonal skills to effectively work with both internal and external customers and responds to requests in a timely and respectful manner.
• Strong verbal, written and interpersonal communication skills.

Responsibilities

• Reviews, interprets, and assigns diagnostic and procedural codes based upon medical record documentation according to correct coding principles.
• Provides skilled and specialized technical work in documentation and coding for medical billing, abstracts complex patient-related data from medical records and coding of diagnoses and procedures using ICD-10 and CPT codes.
• Works coding related charge review and claim edits daily to ensure timely and accurate billing.
• Researches and resolves coding related issues, and assists in meeting productivity and quality standards.
• Contacts other facilities to obtain medical records and information need to bill for services rendered.
• Verifies fee tickets and physician notes for completeness to include abstracting and entering relevant medical information from the medical records; checks for required signatures; assures proper documentation guidelines are followed.
• Interacts with regulator classification agencies and patients when clarification and additional information is required for documentation.
• Updates coding books with changes as accepted and published by regulatory agencies.
• Performs all other duties as assigned.

Skills

ICD-10 coding

CPT coding

Medical terminology

Attention to detail

Customer service

Communication skills

Education

High school diploma or GED

Job description

Under limited supervision, responsible for conducting the quality review of inpatient and outpatient coding, assures coding compliance with federal regulations, and maintains up-to-date coding guidelines and coding policy changes.

Responsibilities

• Reviews, interprets, and assigns diagnostic and procedural codes based upon medical record documentation according to correct coding principles.
• Provides skilled and specialized technical work in documentation and coding for medical billing, abstracts complex patient-related data from medical records and coding of diagnoses and procedures using ICD-10 and CPT codes.
• Works coding related charge review and claim edits daily to ensure timely and accurate billing.
• Researches and resolves coding related issues, and assists in meeting productivity and quality standards.
• Contacts other facilities to obtain medical records and information need to bill for services rendered.
• Verifies fee tickets and physician notes for completeness to include abstracting and entering relevant medical information from the medical records; checks for required signatures; assures proper documentation guidelines are followed.
• Interacts with regulator classification agencies and patients when clarification and additional information is required for documentation.
• Updates coding books with changes as accepted and published by regulatory agencies.
• Performs all other duties as assigned.

Qualifications

• Proficiency in ICD-10 and CPT coding.
• In-depth understanding of medical terminology, anatomy and physiology.
• Meticulous attention to detail and accuracy.
• A solid customer service acumen and interpersonal skills to effectively work with both internal and external customers and responds to requests in a timely and respectful manner.
• Strong verbal, written and interpersonal communication skills.

Education

• High school diploma or GED is required.

Required Skills

• Five (5) years experience in medical record abstraction and coding is required.

This position may require the ability to maintain the security and integrity of UT San Antonio and its infrastructure per Texas EO-GA-48.

Job Info

• Job Category Clinical Programs & Services
• Locations 0126 8431 Fredericksburg Rd, San Antonio, TX, 78229, US (On-site)
• Job Schedule Full time
• Organization M3113 - UTHP ADM Coding Support, M3100 - UTHP UT Health Physicians, M1000 - Dean Medical School, UT Health Science Center, UT Health Science Center
• Department M3113 - UTHP ADM Coding Support